Differences Of Breast Pumps

NURSING DOCUMENTATION

Today when we talk about nursing documentation, we refer mainly folder to nursing.

fact, according to the definition of Rodriguez " the nursing documentation that becomes part of the medical record (or the folder nursing) is the representation in writing the acts performed by nurses in relation to any person, the observations made thereon, the information collected, as well as data concerning the planning of the design expertise of nursing care and related assessments. "

Documentation is important to

Define the core aspects of nursing care;

contribute to the quality of care;

contribute to the transparency of health care;

Differentiate responsibility

Provide criteria for the review and evaluation of care;

Provide criteria for the classification of customers;

Provide data for legal or administrative review;

; adhere to the standards laid down by law or by accreditation;

Provide data for research and experimentation.

nursing

The contents of the folder varies depending on the individual business areas

and their organizational profiles. In general, information to be included in the documentation

correspond to the functions covered by the Ministerial Decree No 739/94

Regulation concerning the identification of the figure and its profile

professional nurse.

The evolution of care, the emergence of greater centrality of the person in the course of treatment, the emergence of nursing as a discipline, will make the nurse is increasingly aware of diagnostic reasoning that led him to identify the problems of the person to assume a resolution path for the care needs and the management of the patient.

The folder is nursing, along with medical records, an integral part of the medical record, as defined in the Handbook of Medical Record Region of Lombardy, is "the organic and functional collection of data relating to individual cases of hospitalization such as, for example, (...) the documentation of non-medical health professionals.

nursing documentation and medical records are then integrated as a function of two things common goal of protecting the health of the person and the community.

The legal framework of nursing directory is not an easy because there is no specific rule governing the document in detail, but being treated at the medical records shall be treated for all purposes constitute an official record compiled by a public official. The notion

effectiveness of public act are described in articles 2699 and 2700 of the Civil Code as "'s paper, with the required formalities by a notary or other public official authorized to attribute public faith in the place where the act is made "and that" is full proof, to be false, the origin of the document by the public officer who trained him, and the parties and other events that occurred in the officer testifies that he made his presence or " .

The nursing documentation, being part of the medical records, must ensure compliance with the requirements for public acts. These requirements are divided into substantive and formal.

I substantive requirements are: Truthfulness, completeness and accuracy, clarity and timeliness.

I formal requirements are: Ø

indication of where you carry out the surveys;

Ø indication of the date, time of the investigation;

Ø Clarification of the name and signature of the person running records;

Ø clarification on the source of the information collected about the history and current needs of the assisted;

Ø Intelligibility handwriting;

Ø Tips and precautions in case of need for correction of clerical errors.

Some rules for the proper completion of documentation can be: v

Always return name, last name and the date that includes day, month, year and time for all registrations;

v Use indelible ink and have a clear and understandable writing;

v Using language and terminology accurately and verified;

v Use symbols and abbreviations provided compositions and notes from around the health care team, providing a map available;

v Building the documentation for themselves, never on behalf of others, taking responsibility for their own records;

v not insert personal views;

v not tear pages they use ink removers or whitebait but to correct the mistake by drawing a line above so that it is readable and write the correction below;

v not forget to add information using a confined space;

v Do not leave gaps between recording and the other;

v signed legibly, use of abbreviations is allowed only if the same are filed.

(Excerpt from my thesis for coordination)